Sequential therapy for immune reconstitution in multiple sclerosis: a clinical case of use of cladribine tablets after alemtuzumab

The use of alemtuzumab in the treatment of multiple sclerosis may be limited by the development of autoimmune complications and the persistence of disease activity in some patients. In such situations, the strategy of repeated courses of the drug is not always effective due to the possible formation of neutralizing antibodies, and anti-B-cell therapy has limitations associated with concomitant pathology. The literature describes the possibility of sequential use of two drugs from the class of immune reconstitution therapy - alemtuzumab and cladribine tablets, which allows achieving clinical and neuroimaging stabilization without the need for constant treatment. We present a clinical case of a patient with highly active relapsing-remitting multiple sclerosis, who, after two courses of alemtuzumab, remained active and developed autoimmune complications. Sequential therapy with cladribine tablets ensured control of the disease, stabilization of the neurological status and neuroimaging data, as well as the absence of serious infectious complications. This experience confirms the potential effectiveness and safety of the “alemtuzumab → cladribine tablets” strategy, but emphasizes the need for further accumulation of clinical data to assess its place in the therapeutic arsenal.